Drugs Used in the Treatment of UveitisGeneral Principles

The purpose of this article is to describe the different drugs used in
the treatment of uveitis. The term drug would include eye drops, tablets
and injections. Treatment of uveitis may also include the use of surgery
and lasers but these are not being dealt with in this article.

The reasoning behind treatment has been covered in another fact sheet,
The Treatment of Uveitis".
It is always worth repeating the fact that there are many different
types of uveitis and a great deal of variation between individual cases.
This means that the treatments will vary enormously and that some of the
drugs described below will not sound familiar at all to some of us. No
attempt has been made to make a list of all the names of the drugs used.
There are many different trade names and there are no "best" drugs, as
cases vary so much.

Before describing the different groups of drugs, it may be useful to
remember the aims of treatment in uveitis:

What should treatment achieve?

Relieve pain and discomfort.

Prevent sight loss due to the disease or its complications.

Treat the cause of the disease where possible, that is, treat
the inflammation.

The above 3 different aims of treatment explains the wide variety of
drugs used in treating uveitis. In a few types of uveitis, the
inflammation is caused by an infection and so patients are treated with
antibiotics or antiviral drugs. Apart from this situation then the drugs
used to treat uveitis fall into 3 main groups: Steroids, Immunosuppressants
and Mydriatics (pupil dilators).

Steroids

Apart from certain types of uveitis caused by infections, (see above)
the majority of cases are treated by altering the activity of the immune
system. The immune system has recognised a part of our own body as
foreign and reacts against it. This reaction is called inflammation. The
action desired by those treating uveitis is to suppress the immune
system or to "turn it down".

Steroids have wide ranging effects but their action may be looked on as
being anti-inflammatory and immunosuppressant".

The method used to "deliver" the steroid
depends on the severity of the uveitis and where, in the eye, the
inflammation is.

Eye Drops

Steroid drops are used for Anterior Uveitis (iritis or iridocyclitis).
The drops can penetrate the part of the eye in front of the lens, where
anterior uveitis occurs.

There are many different names of drops and for that reason a list of
different drops is not included here. Basically the drops will differ in
their strength. The frequency of taking the drops will also vary
depending on the severity of the uveitis.

In a very severe case, the strongest drop may be used every hour
initially, whereas someone else with a mild inflammation may only need
to use the weakest drop once or twice a day. Anterior uveitis, remember,
may be acute, (coming on suddenly and stopping in weeks) or chronic
(coming on slowly and lasting for months or years).

This will also affect the length of time that drops are taken for.

As a general rule the treatment with drops is started off very
frequently with stronger drops to reduce the inflammation as quickly as
possible. The treatment would then be "tapered off" gradually before
being stopped. This is important because potentially the eye may be
damaged by even short periods of inflammation if not treated vigorously
enough.

Periocular Injections

Sometimes it is considered necessary to use injections around the eye to
deliver the steroid treatment. There are only certain situations where
injections offer a better way forward than either tablets or drops. They
are usually used along with other forms of treatment.

Situations where injections are used include:

Severe cases of Anterior uveitis which can not be controlled by drops alone.

Intermediate Uveitis.

To avoid or limit systemic steroids in the younger age groups. This is
to avoid the side effects of systemic steroids which are more
significant in children. ( see next section; -systemic drugs).

From the patient's point of view it is fairly obvious what the
drawback of the injection is. If given a choice between taking the same
drug by drop, tablet or injection, you wouldn't need a questionnaire
to find out that the injection wouldn't get many votes. Injections,
as stated before, are only considered in certain situations when they
are thought necessary. Injections may have distinct advantages over
other means in some situations.

Injections do vary in type and the discomfort of the injection itself
and its after effects will vary. Usually they are straightforward and
not too uncomfortable. If our doctor thinks that injections would be
necessary, then we mustn't be afraid of asking what is involved.
This is particularly the case with children where the use of a general
anaesthetic is sometimes considered.

Systemic Steroids

Oral Steroids

Prednisolone is the name given to the tablets likely to be used.
The use of systemic steroids is more serious than, say, steroid drops
because in this form there are potentially significant side effects. It
becomes even more important to be able to talk to our doctors about the
benefits and the risks of the treatment. (see also The Treatment of Uveitis).

There are many different situations in which oral steroids are
considered. So far we have seen how Anterior uveitis is usually treated
by drops alone. In certain circumstances, then injections may be used.
If Anterior uveitis is particularly severe or resistant to treatment
with drops and/or injections then it is possible that systemic steroids
may be considered. However, the main use of oral steroids is to treat
those types of uveitis that affect the back of the eye, (posterior
uveitis, retinochoroiditis and panuveitis are examples of several terms
used).

Dosage

Prednisolone is usually found as 1milligram (mg.) and 5mg. tablets. The
dosage usually starts off very high and then the inflammation is
observed very closely and when it is being controlled the dosage will be
gradually tapered off to the lowest possible dose which will keep the
inflammation from recurring. It will come as no surprise that there are
no typical dosages or times for the tapering off period! As we know by
now there are so many different types of uveitis, there may be one or
both eyes involved, the uveitis may be severe of mild and so on. However
the range of high dosage would be considered to be 40-80mg. At the other
end, if the steroid can not be discontinued altogether, then it is
thought that dosages of 7.5 mg and below give rise to "acceptable" risks
of side effects. If the uveitis seems to be resistant to the steroid
therapy or if the inflammation starts up again when the steroids drop
below, say, 40mgs. then other immunosuppressants may be used along side
the steroids. (see below)

Taking our medicine!

It is very important to have a good routine when we take steroid
tablets. The effects of missing daily dosages of steroids can be
significant. To make sure we keep good control of our uveitis it is
essential that we have a set routine. Using a calendar, stuck to a box
with the drugs in them is an example of how easy it can be to make sure
we never miss a dose.

Keep to the instructions given by the clinic.

Steroids are usually taken before breakfast each day.

Never stop taking steroids or reduce their dosage. This can be very dangerous.

Contact your doctor if you develop any illnesses, especially infections.

Always carry a steroid card. Think about carrying a bracelet or
necklace such as provided by Medicalert (Tel: 0207833 3024)

Intra-venous Steroids

Occasionally, a situation may arise when rapid control of an acute
episode of inflammation is needed. This may be if the sight is
threatened and a high dosage of steroid needs to be delivered quickly.

In this case a steroid called methylprednisolone may be used. It is
given by means of an intravenous infusion ( a drip) . The dose is
infused over approx. 2 hours and is usually repeated 24 hours later for
upto 3 doses. This procedure is normally carried out in a hospital ward
because close monitoring of side effects and reactions eg blood pressure
are required.

A rapid effect hopefully follows so that a routine of oral drug
treatment can be resumed.

Side Effects of Steroids

A large separate article, or even a book, could easily be written about
the side effects of steroids We must be careful when we think about
this. On one hand, there can be serious side effects which can be
troublesome and have to be appreciated when balancing benefit and risk
of treatment. On the other hand, most of us who take steroids will only
experience a few, if any, significant side effects. So we must respect
the list of possible problems caused by taking steroids, but we
mustn't panic when we see the "long list".

The side effects of systemic steroids, then, include the following:

Nausea, dyspepsia(heartburn)

Increased appetite, weight gain and fluid retention

Mood changes, including depression or euphoria.

Hypertension, (high blood pressure).

Increased hair growth

Diabetes

Osteoporosis

Bruising and delayed wound healing

Growth suppression in children.

Cataract

Glaucoma (raised eye pressure).

Most of these effects are monitored at your eye clinic, using blood
tests etc. but if you are concerned about any side effects you should
ask your doctor.

The side effects are not being dealt with in detail here. Please contact
the UIG if you are interested in following up any of the side effects
and more detailed general information is available. There is also a UIG
Fact sheet for Prednisolone.

To end the section on side effects on a positive note, virtually all the
problems listed above can be minimised by a combination of a good diet
and plenty of exercise, a subject which will feature in the next
newsletter. As said before, steroids make up the mainstay of treatment,
but we will now take a briefer look at the two other important groups of
drugs.

Immunosuppressants

Steroids do suppress the immune system in a general way, but there are a
different group of drugs that may be used to treat some forms of
uveitis, in certain situations. These drugs tend to target the immune
system more precisely than steroids. They are usually used in
conjunction with steroids. All these drugs have there share of side
effects. The main examples are:

Cyclosporin

Azathioprine know as Imuran

Methotrexate

Mycophenolate mofetil often know as cellcept,

Tacrolimus, also knows as Prograf 500

The group has specific information on this group of drugs on request. If
you are taking a drug which you think may be of this type and wish to
know more about it then please contact the group.

Mydriatics

Mydriatics are used in the treatment of anterior uveitis and have 2 main aims.

To relieve pain and light sensitivity.

To prevent sight threatening complications.

Mydriatic eye drops, such as atropine and cyclopentolate, are used.
Again there are many names of these type of drops, but they are grouped
into "long" or "short" acting. They may be used for variable lengths of
time depending on individual cases. A mydriatic works by "paralysing"
the muscles of the iris and the ciliary body. (it is the movement of
these inflamed muscles that causes the pain). When these drops have
taken their effect the pupils will be dilated. This may cause blurring
of the vision.

The mydriatics are also useful because they help prevent a complication
which may occur in anterior uveitis where the inflamed iris "sticks" to
the lens. This is known as adhesions or synechiae. This can lead to a
raised pressure in the eye which may be sight threatening if not
treated.

The use of mydriatics is simple but the blurring of near vision, for a
while after they are put in, can be disruptive for some patients at work
or at home.

It is important, then, to remember that these drops are not just
relieving pain and discomfort but they can be very important in
preventing significant complications later on.

This factsheet was written by Phil Hibbert
B.D.S. L.D.S. R.C.S., patient. It has been verified by a panel of
experts which include uveitis specialists.last updated Dec 06